Injuries and inequities - WHO/Europe

Injuries and inequities
Guidance for addressing inequities
in unintentional injuries
Injuries and inequities
Guidance for addressing inequities
in unintentional injuries
Written by: Francesco Zambon
Belinda Loring
Abstract
This policy guidance aims to support national, regional and local policy-makers in Europe to prepare,
implement and follow up policy actions and interventions to reduce inequities in unintentional injuries.
Unintentional injuries, including road traffic injuries, falls, burns, drownings and poisonings still constitute
a major public health problem, killing almost half a million people in the WHO European Region each year
and causing many more cases of disability. The burden of unintentional injuries is unevenly distributed in the
WHO European Region. Steep social gradients for death and morbidity exist across and within countries.
Reducing health inequities is a key strategic objective of Health 2020 – the European policy framework
for health and well-being endorsed by the 53 Member States of the WHO European Region in 2012. This
guide seeks to assist European policy-makers in contributing to achieving the objectives of Health 2020 in
a practical way. It draws on key evidence, including from the WHO Regional Office for Europe’s Review of
social determinants and the health divide in the WHO European Region. It sets out options and practical
methods to reduce the level and unequal distribution of unintentional injuries in Europe, through approaches
that address the social determinants of unintended injuries and the related health, social and economic
consequences.
Keywords
HEALTH POLICY
INJURIES
SOCIAL DETERMINANTS OF HEALTH
SOCIOECONOMIC FACTORS
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Contents
Acknowledgements and contributions
iv
Forewordv
Introduction1
Purpose of this guidance
1
Using this guide
2
Relevance to other key European policy goals
3
Inequities in unintentional injuries in Europe 5
What can be done?
9
Step-wise approach
10
“First do no harm”
11
Policy interventions at different levels 15
Socioeconomic context and position
15
Differential exposures
17
Differential vulnerabilities
20
Differential health outcomes
22
Differential consequences
22
Where to find out more 27
Unintentional injuries in Europe
27
Policy options to address unintentional injuries
27
Actions to reduce health inequities through action on SDH
27
Policy equity assessment tools
28
Data disaggregation and tools
28
References29
iii
Acknowledgements and contributions
This document was written by Francesco Zambon and Belinda Loring, WHO European
Office for Investment for Health and Development, Venice, Italy.
The following people provided helpful comments and expert technical review:
• Francesco Mitis, Dinesh Sethi, Erio Ziglio, Åsa Nihlén and Sara Barragán Montes,
WHO Regional Office for Europe
• Margaret Whitehead, WHO Collaborating Centre for Policy Research on Social
Determinants of Health, University of Liverpool, Liverpool, United Kingdom
• Sue Povall, WHO Collaborating Centre for Policy Research on Social Determinants
of Health, University of Liverpool, Liverpool, United Kingdom
• Neil Riley, Public Health Wales, Cardiff, United Kingdom
• Chris Brookes, UK Health Forum, London, United Kingdom
• Charles Price, European Commission Directorate-General for Health & Consumers,
Brussels, Belgium
• Nabil Safrany, European Commission Executive Agency for Health and Consumers,
Luxembourg.
Further comments were also provided by the European Commission DirectorateGeneral for Health & Consumers, the Executive Agency for Health and Consumers and
the European Union Expert Group on Health Inequalities.
This document has been produced with the financial assistance of the European Union.
The views expressed herein can in no way be taken to reflect the official opinion of the
European Union.
The WHO European Office for Investment for Health and Development of the WHO
Regional Office for Europe also wishes to thank the Italian Ministry of Health, the Veneto
Region and the Tuscany Region for their long-standing support to the work of the office
as well as the financial support for this publication.
iv
Foreword
Overall population health indicators have improved across Europe over recent decades,
yet that improvement has not been experienced equally everywhere, or by all. There
are widespread inequities in health between and within societies, reflecting the different
conditions in which people live. These health inequities offend against the human right
to health and are unnecessary and unjust.
Health 2020 is a new value- and evidence-based health policy framework for Europe,
supporting action across government and society to promote health and well-being, the
reduction of health inequities and the pursuit of people-centred health systems. It was
adopted at the 62nd session of the Regional Committee held in Malta in September
2012. Its commitment is to health and well-being as a vital human right, essential to
human, social and economic development and a sustainable and equitable Europe.
Health is a fundamental resource for the lives of people, families and communities.
To make this vision a reality we need to tackle the root causes of health inequities
within and between countries. We know more about these now from the 2013 report
of the European review of social determinants of health and the health divide, led by
Professor Sir Michael Marmot and his team at the University College London Institute of
Health Equity. Yet opportunities to be healthy are far from being equally distributed in our
countries, and are closely linked to good upbringing and education, decent work, housing
and income support throughout our life course. Today’s disease burden is rooted in how
we address these social factors that shape current patterns of ill health and lifestyles,
and in the way our resources are distributed and utilized.
For these reasons I welcome the publication of this series of policy briefs, which
describe practical actions to address health inequities, especially in relation to priority
public health challenges facing Europe: tobacco, alcohol, obesity and injury. I hope this
series will offer policy-makers and public health professionals the tools and guidance
they need to implement the Health 2020 vision and the recommendations of the social
determinants review. The policy briefs were prepared in collaboration with the European
Union and I would like to express my gratitude for this support and for the recognition
that the European Union and WHO both share this common commitment to addressing
equity.
Achieving the promise of Health 2020 will depend on successful implementation of the
relevant policies within countries. We can and must seize new opportunities to enhance
the health and well-being of all. We have an opportunity to promote effective practices
and policy innovations among those working to improve health outcomes. The present
(often extreme) health inequities across our Region must be tackled and the health gap
among and within our European Member States reduced.
Zsuzsanna Jakab WHO Regional Director for Europe
v
Introduction
Purpose of this guidance
This policy guidance aims to support national, regional and local policy-makers in Europe
to prepare, implement and follow up policy actions and interventions to reduce inequities
in unintentional injuries.
The term injury refers to the physical damage that results when a human body is suddenly
subjected to energy in amounts that exceed the threshold of physiological tolerance,
or damage resulting from a lack of one or more vital elements, such as oxygen (1).
This policy brief addresses a broad group of unintentional injuries that are categorized
according to their main causal mechanism: road traffic injuries, falls, burns, drowning and
poisonings.
In the past, injuries were regarded as random, unavoidable accidents. In recent decades,
due to a better understanding of underlying mechanisms, injuries are now regarded as
largely predictable and preventable (2, 3). Unintentional injuries still constitute a major
public health problem, killing almost half a million people in the WHO European Region
each year and causing many more cases of disability.
The burden of unintentional injuries is unevenly distributed in the WHO European Region.
While mortality rates from unintentional injuries have declined on average across the
Region, in the Commonwealth of Independent States mortality rates have fluctuated
vastly since the mid-1990s and continue to be the highest in the Region. Steep social
gradients for death and morbidity exist across and within countries. People with lower
levels of education, lesser occupations and/or lower income not only have a higher risk
of incurring injuries, they also risk suffering more severe consequences when injury
occurs (3).
Generally speaking, many interventions have proven to be effective in preventing,
reducing or mitigating injuries. Measures include products (seat belts or smoke detectors,
and flame-resistant clothing), environmental changes (speed bumps, swimming pool
fencing), public education (social marketing campaigns, parent training), and policy
guidelines or laws (legislation on drink–driving). Many such measures have also proven
to be highly cost-effective.
While very little evidence exists on the differential impacts of safety interventions on
various socioeconomic groups, the widening of socioeconomic inequalities in injuries
necessitates that policy-makers incorporate the equity dimension in approaches used to
tackle injuries (3). Preventive interventions should be designed so that they effectively
counteract the underlying mechanisms of injury, which can be different in each social
group. This policy document provides technical guidance on how to prepare, implement
and follow up such interventions in practice.
1
Injuries and inequities
Key messages
• Policies and interventions addressing unintentional injuries must be implemented with a clear
view to have at least as much (if not more impact) on vulnerable groups compared with the
rest of the population, in order to close the gap.
• Unintentional injuries (which include road traffic injuries, falls, burns, drowning, and poisonings)
kill almost half a million people per year in the WHO European Region. Deaths are only the
tip of the iceberg; there are many non-fatal injuries for each death that occurs, often with farreaching health and social consequences.
• The burden of injuries is unequally distributed. In addition to differences across countries,
there is a steep social gradient within countries.
• Unintentional injuries are predictable and preventable. Effective safety interventions can
prevent, reduce or mitigate injuries.
• There is little evidence to show how safety interventions might impact differently on various
socioeconomic groups. The possible differential impact on different socioeconomic groups
needs to be evaluated for any policy and/or intervention.
• Policies and interventions need to be designed with knowledge of the underlying mechanism
of injury, in order to effectively counteract health inequities.
Using this guide
The pattern of inequities in injuries varies greatly between and within countries in Europe.
It is therefore not possible to make specific policy recommendations that will work in all
countries. This guide provides a framework that policy-makers at national, regional and
local levels can apply to their own unique context, in order to consider the processes by
which inequities might occur, and to suggest policy interventions that may be helpful in
addressing each of these factors. Additional resources are listed at the end of the guide
to direct policy-makers to further evidence, promising practices and tools to support
policy formulation and evaluation.
Not all European countries have data on unintentional injuries that can be disaggregated
by socioeconomic factors beyond age and sex. There are very few published studies
of interventions to address injuries which focus on equity or the distribution of impacts
within the population. Additionally, given that countries in the WHO European Region
have different models of social stratification, the evidence at hand – which stems from
high-income countries – is not directly applicable in all cases (3).
Efforts to improve geographical and social data disaggregation, including both individual
and contextual variables, will enhance the ability to monitor the differential impacts of
policies and interventions on social groups.
2
Guidance for addressing inequities in unintentional injuries
Relevance to other key European policy goals
Reducing health inequities, along with improving governance for health and health equity
are key strategic objectives of Health 2020 – the European policy framework for health
and well-being endorsed by the 53 Member States of the WHO European Region in
2012. Tackling the major challenges posed by noncommunicable diseases and injuries is
one of Health 2020’s policy priorities. To achieve these objectives, Health 2020 strongly
emphasizes the need to strengthen population-based prevention, and accelerate action
across levels of government on the social determinants of health (SDH). Similarly, in
2009 the European Commission adopted a communication entitled “Solidarity in health:
reducing health inequalities in the EU” (4) and the importance of addressing health
inequalities is clearly stated in the European Union (EU) Health Strategy (5).
Among the initiatives which specifically boost safety action, the United Nations’ Decade
of Action for Road Safety 2011–2020 is a unique opportunity to shape the political
agenda towards safer societies. The related Global Plan calls for a systematic approach
and multisectoral action involving governments, academia, the private sector, civil
society, the media, victims and their families. Action points are grouped in five categories
or pillars: (1) road safety management, (2) safer roads and mobility, (3) safer vehicles,
(4) safer road users, and (5) post-crash response (6).
3
Inequities in unintentional injuries in Europe
Health inequities are defined as systematic differences in health that can be avoided by
appropriate policy intervention and that are therefore deemed to be unfair and unjust. To
be able to devise effective action, it is necessary first to understand the causes of these
inequities in health. Health inequities are not solely related to access to health care
services; there are many other determinants related to living and working conditions,
as well as the overall macro-policies prevailing in a country or region (Fig. 1). Inequities
in health are caused by the unequal distribution of these determinants of health,
including power, income, goods and services, poor and unequal living conditions, and
the differences in health-damaging behaviours that these wider determinants produce.
tural and env
ic, cul
iron
m
o
me
on
c
nta
e
o
i
Living
and
working
lc
c
o
so
conditions
Unemployment
s
rk
rs
to
community ne
nd
tw
a
o
ial
al lifestyle fa
u
c
d
vi
Ind
i
Education
So
c
Work
environment
Agriculture
and food
production
ns
itio
nd
Ge
ne
ra
l
Fig. 1. The main determinants of health
Water and
sanitation
Health
care
services
Housing
Age, sex and
constitutional
factors
Source: Dahlgren & Whitehead (7).
Unintentional injuries are a major public health problem, accounting for almost half a
million deaths annually in the WHO European Region, which constitutes 7% of all deaths
(8). These injuries are categorized according to their main causal mechanism: road traffic
injuries, falls, burns, drowning, and poisonings. Other mechanisms, such as electric
current or exposure to mechanical forces, also account for a large number of injuries.
The general approaches for prevention, however, are common to all.
The largest proportion of unintentional injuries is attributable to road traffic accidents,
followed by poisoning and falls. These injuries are among the 10 leading causes of
death among the population aged 0–59 years. In the age group 5–29 years, road traffic
injuries are the leading cause of death, taking the lives of about 35 000 people annually.
However, the distributional pattern of fatal injuries greatly varies according to the age
group (Fig. 2) (8–12).
5
Injuries and inequities
Fig. 2. Deaths by unintentional injuries as a percentage of total deaths in the WHO European
Region, by injury category, both sexes, 2011
45
40
35
30
25
%
20
15
10
5
0
0–4 5–14 15–2930–4445–59 60–6970–79 80+
Age
 Other unintentional injuries
 Drownings
 Fires
 Falls
 Poisonings
 Road traffic accidents
Source: WHO Regional Office for Europe (8).
Deaths are only the tip of the clinical iceberg; there are many non-fatal injuries for each
death that occurs, often with far-reaching health and social consequences. A study in
the Netherlands, for example, showed that for every death from injuries occuring in the
home or during leisure, there were 160 hospital admissions and 200 emergency room
attendances (10, 13).
Mortality rates from unintentional injury in Europe are higher in males than in females,
and male deaths by drowning are 4.6 times as frequent as female deaths by drowning.
However, the male–female ratio varies according to the category of injury (Fig. 3) (8).
Conflicting evidence is available regarding socioeconomic differences in relation to
gender (3). A study conducted in eight countries showed that men with lower levels
of education generally have an increased death rate from transportation injury (in an
all-country setting). However, analysing the social pattern for women and its relation to
injury risk has led to conflicting results (14).
The burden of unintentional injuries is not equally distributed in the WHO European Region.
Although countries in western Europe have reached good safety levels, death and disability
from injury still remain high in eastern European countries. The WHO European Region
shows the biggest difference in injury mortality between poor and wealthy countries in
the world. Overall, the risk of dying of unintentional injuries in low- and middle-income
countries is three times higher than in high-income countries. However, when considering
specific causes of injuries, inequity gaps of a much greater magnitude are evident. For
instance, the mortality rate for road traffic crashes is 3 per 100 000 in Sweden, while in
Kazakhstan it is seven times this (9). In addition to these differences across the Region,
disparities also exist within countries, without exception.
6
Guidance for addressing inequities in unintentional injuries
Fig. 3. Male to female ratios of deaths by injury in the WHO European Region, 2008
5
4.5
4
Rate ratios
3.5
3
2.5
2
1.5
1
0.5
0
Road traffic
injuries
Falls
Poisonings
Drownings
Fires
Source: WHO Regional Office for Europe (8).
In general, the disadvantaged in any country are at a higher risk of both fatal and
non-fatal unintentional injury compared to the more advantaged members of society.
Vulnerability, exposure and consequences of injuries are borne differently by the different
socioeconomic strata (15–17). Children and people in disadvantaged groups may suffer
from malnutrition and co-morbidity, making them more susceptible to worse outcomes
after the injurious event. Furthermore, injuries accentuate the cycle of poverty, as the
more vulnerable groups are less likely than wealthy individuals to pay co-payments for
medical care, to afford time off from work or to be insured.
For instance, in England and Wales, children from worse-off families are 37.7 times
more likely to die from exposure to smoke and fire than children from well-off families
(18). The mechanisms which lead to injury vary in different social groups. Improving
safety requires flexible and multifaceted interventions based on a thorough knowledge
of communities (3).
Research has shown that the more preventable an ailment, the stronger the relationship
between health outcomes and socioeconomic level. The disadvantaged have less
access to safety equipment, to education and programmes to change unsafe behaviours
– to mention only a few means of prevention. Affluent people have a range of resources,
making prevention more accessible. Moreover, once injury has occurred, accessibility
and affordability of high-quality medical care can lead to inequities, further increasing the
burden of injuries for the poor (19).
Very few policies and interventions incorporate the equity dimension in their design.
Further evaluation of differential impact across socioeconomic groups would be
advantageous.
7
Injuries and inequities
Key messages
• Unintentional injuries are a leading cause of death.
• The burden of injuries is unequally distributed across socioeconomic groups. People with
lower levels of education, income and occupation are at a higher risk of unintentional injuries
than those who are better off.
• Males are more affected by death and disability than females, in terms of all types of
unintentional injuries.
• Preventive interventions might effectively increase the overall level of safety in a population,
but may not decrease inequities across different socioeconomic groups.
• Despite solid evidence documenting inequities in unintentional injuries, few policies and
interventions incorporate the equity dimension in their design.
• The complex interplay of individual, community and structural variables leads to different
underlying injury mechanisms in various socioeconomic groups. Safety measures need to be
based on this knowledge.
8
What can be done?
Unintentional injuries impose huge costs to societies, which could be abated. It is estimated
that road traffic accidents alone reduce a country’s gross domestic product by up to 3.9%
(8). Furthermore, costs associated with medical care and the loss of income resulting from
injuries can lead already disadvantaged people to further impoverishment, and push them
into the medical poverty trap.
Cost-effective interventions exist to reduce the overall burden of unintentional injuries.
They have high returns on investment through their saving of economically productive
human lives. One study conducted in England demonstrates that significant savings can
be made by preventing emergency department attendances and hospital admissions
for unintentional injury among children and young people. An 11% national reduction in
unintentional injuries among children could save enough funding to offset the cost of
implementing the preventive interventions (20). Despite striking evidence of the steep
social gradient for all types of injuries, it is unusual to find policies and interventions which
articulately address the equity dimension in such a way that the impact on different social
groups is foreseen (3). This results in a lack of knowledge about whether they are equally
effective in all socioeconomic groups and about whether they progressively reduce the
injury risk for those most vulnerable. Those interventions that target disadvantaged groups
typically involve measures such as the adoption of safe practices and the use of safety
equipment. However, these might not suffice in decreasing the injury risk level (21).
Equity-oriented interventions should be designed so that they effectively counteract
underlying mechanisms of injury, which can be different in each social group. These
interventions need to progressively increase the level of safety of the groups most in
need, through concerted, multisectoral actions. Safety-for-all strategies such as legislation,
regulation and enforcement are effective in reducing injuries in all social groups. These
include setting minimum conditions and product standards and imposing safe behaviour
and practices, such as wearing seat belts in cars. Whereas it is generally accepted that
passive, universally targeted interventions, such as road traffic safety management are
most effective in reducing the injury burden, it is not known whether they differentially
favour disadvantaged people, thus reducing inequities across socioeconomic groups (3).
Effective approaches tend to focus on the distinct pathways and mechanisms by which
safety differentials arise. Equity-oriented policies and interventions aim to narrow inequities
through action targeted at reducing the exposure to, risk of and consequences of injury for
less-affluent people or neighbourhoods (22).
There are a number of approaches to preventing socioeconomic inequalities in unintentional
injuries, focusing on various aspects of prevention (7, 23).
9
Injuries and inequities
•
Primary prevention
Opportunities for safety: some people face higher
structural risks, such as children living near areas with
high-speed traffic.
•
Secondary prevention
Opportunities to avoid risk: some people are less able
to avoid injury. Not all can afford child car restraints, for
example.
•
Tertiary prevention
Access to or use of health care: some people live in
areas lacking emergency trauma care and rehabilitation
services.
Such interventions should be part of larger social welfare policies and policies promoting
social mobility.
Step-wise approach
Countries in Europe have very different experiences and capacities to address health
inequities; however, no matter what the starting point, something can be done. An
incremental approach can be taken to reducing inequities, wherever one begins (see
Fig. 4).
Fig. 4. Incremental approach to reducing inequities
Ensure policy
choices do not
make inequities
worse
Focus on
addressing
health
consequences
for most
disadvantaged
Reduce the gap
between most
advantaged
and most
disadvantaged
Seek to
flatten the
gradient across
the whole
population
It is not only the most disadvantaged who suffer a disproportionate burden of
unintentional injuries. A social gradient exists, whereby each socioeconomic group is at
relatively higher risk of unintentional injury than the next group above them in the social
spectrum. Addressing gaps between groups and reducing the social gradient requires
a combination of universal policies and additional measures according to the different
levels of need involved.
10
Guidance for addressing inequities in unintentional injuries
“First do no harm”
Some public health interventions inadvertently make inequities worse. Unless
equity is explicitly taken into consideration, the business-as-usual approach tends to
create policies, programmes and services that have a social gradient in their effect.
Unfortunately, although this is not the policy-makers’ intent, it means that the most
disadvantaged groups receive the least benefit from the policy, even though they have
the most to gain, and inequities worsen rather than improving.
For example, a study from the United Kingdom assessed the effectiveness of home
safety interventions, which included safety consultation and provision of free safety
equipment to a large sample of families. The study found that ethnic minority families
were less likely than non-minority families to engage in home safety practices (such as
storing medicine and cleaning products safely), widening inequities rather than narrowing
them (24).
This seems to be especially true for broad public education campaigns and individual
health promotion interventions, which often have the most impact on people who are
better off. This does not have to be the case, however (25, 26). Some measures, such
as traffic calming, are effective in reducing pedestrian injuries for all socioeconomic
groups. Traffic calming can also reduce relative inequalities in child pedestrian injuries
(27). Even good strategies to prevent unintentional injuries have not been evaluated for
their effectiveness in different socioeconomic groups. It cannot be assumed that these
measures will have the same effects across society. A number of tools are available for
assessing the equity impact of policies and interventions (see the section on where to
find out more at the end of this policy brief).
The formulation of policies and interventions can benefit from a set of 10 well-known
strategies for the prevention of injury (28). They target both stages of the injury process,
as well as areas of change. No thorough evaluation has assessed these strategies
through an equity lens. However, presumably the closer a given intervention is to targeting
the source of danger by modifying, eliminating, separating or isolating it (passive safety),
the greater its potential for reducing inequities in injury risk. Conversely, the more an
intervention relies on adopting safe behaviour (active safety) in difficult living, working
or road environments, the less effective it is likely to be among deprived individuals
and communities, unless accompanied by enforcement (3). As such, it is less likely to
contribute to narrowing the safety gap. Table 1 shows the 10 strategies developed by
Haddon and their impact on inequities (28).
The policy-maker has three approaches available to implement such strategies:
• population-based programmes with the same intervention for all groups;
• programmes targeting most-at-risk groups;
• population-based programmes with personalized interventions for different groups.
11
Injuries and inequities
Legislation, regulation and enforcement are safety-for-all strategies and have proven
to be effective in reducing the overall burden of injuries. Targeted programmes aim
to identify people at risk and decrease their exposure and vulnerability to risk, as well
as preventing unequal consequences of injuries. This can be achieved, for instance,
through educational programmes and the distribution of free safety equipment to the
groups at greater risk (29).
Table 1. 10 strategies for injury prevention and their potential impact on inequities
Haddon’s ten
strategies
for injury
prevention
and control
Type of
intervention
Aim of
policy/
intervention
Examples
Impact on
inequities
Eliminate the
hazard
Legislation,
regulations,
infrastructures
Limiting
exposure
–
Likely to increase
safety for all
Separate the
hazard
Legislation,
regulations,
infrastructures,
provision of
safety devices
Limiting
exposure
Falls: stair
gates
Education
programmes
related to the use/
possession of stair
gates were more
effective among
disadvantaged
families compared
to their controls
(30)
Falls: window
locks
Education
programmes
related to the
use/possession
of window
locks were less
effective among
disadvantaged
families compared
to their controls
(21)
Fencing for
public aquatic
facilities/
locations;
installing
barriers for
cliff edges
Likely to increase
safety for all
Isolate the
hazard (time
and space)
Legislation,
regulations,
infrastructures
Limiting
exposure
12
Guidance for addressing inequities in unintentional injuries
Table 1. contd
Haddon’s ten
strategies
for injury
prevention
and control
Modify the
hazard
Equip the
person
Type of
intervention
Legislation,
regulations,
infrastructures
Safety
standards,
pricing policies
of safe
equipment,
free
distribution
of safe
equipment
Aim of
policy/
intervention
Limiting
exposure
Limiting
vulnerability
13
Examples
Impact on
inequities
Scalds: safe
hot tap water
temperature
Education
programmes
related to thermal
injury prevention
were more effective
in disadvantaged
families compared
to their controls
(21)
Road traffic
injuries: traffic
calming
Traffic calming
is associated
with reduction
in absolute
pedestrian
injury as well
as reduction in
relative inequities
in child pedestrian
injury rate (27)
Burns: flameresistant
nightdresses
Does not
prevent injury,
but significantly
contributes to
the reduction of
fatal injuries for
members of all
social groups (3)
Road traffic
injuries:
legislation
on bicycle
helmets
Bicycle helmet
legislation is
effective in
increasing helmet
use by all children
and particularly
those in lowincome areas (31)
Fires: smoke
detectors
Equal impact on
all socioeconomic
groups (32, 33)
Injuries and inequities
Table 1. contd
Haddon’s ten
strategies
for injury
prevention
and control
Type of
intervention
Aim of
policy/
intervention
Examples
Impact on
inequities
Train and
instruct the
person
Home visiting
programmes,
social
marketing
campaigns,
training
courses, law
enforcement
Limiting
vulnerability
Road traffic
injuries:
populationbased
education
programmes
combined with
affordability
and
accessibility of
cycle helmets
Programmes had a
positive impact on
head injuries both
in rich and poor
municipalities (34)
Warn the
person
Home visiting
programmes,
social
marketing
campaigns,
training
courses, law
enforcement
Limiting
vulnerability
Road traffic
injuries:
populationbased
education
programmes
combined with
affordability
and
accessibility of
cycle helmets
Programmes had a
positive impact on
head injuries both
in rich and poor
municipalities (34)
Supervise the
person
Parenting
programmes,
law
enforcement
Limiting
vulnerability
Interventions
to prevent
drowning
More impact on
disadvantaged
groups (21)
–
Likely to
increase safety
in disadvantaged
groups
Rescue the
person
Improving
trauma care in
deprived areas,
increasing
accessibility
and affordability
of care
Improving
health
outcomes
–
Likely to limit
long-term
consequences
of injuries in
disadvantaged
groups
Repair and
rehabilitate the
person
Increasing
accessibility
and affordability
of care, social
welfare, social
protection
Limiting health
consequences
–
–
14
Guidance for addressing inequities in unintentional injuries
Key messages
• Well-intentioned public health interventions often make health inequities worse – equity
needs to be explicitly considered in the design of all policies and programmes to address
unintentional injuries.
• Do not assume that what works on average, works for everyone – it is essential to investigate
the effect of interventions on different socioeconomic groups.
• All policies need to be monitored to ensure they work effectively in practice to deliver the
intended equity results.
• Modifying, isolating and/or eliminating the source of danger have great potential for reducing
inequities in injury risk in all socioeconomic groups (passive safety).
• Interventions that rely on adopting safe behaviour (active safety) are likely to be less effective
among deprived groups.
Policy interventions at different levels
Inequities in unintentional injuries can arise from factors at many levels. This
includes factors in the broader socioeconomic context, different exposures,
different vulnerabilities, different experience within the health system, and different
consequences from injuries (Fig. 5). For the most disadvantaged in society, inequities
exist at all of these levels, leading to compounding disadvantage.
For example, poor, socially excluded groups are more likely to have increased exposure
to unsafe housing and dangerous traffic environments, they have reduced access to
information and safety instructions, are less likely to pay for car and home insurance,
and have less access to high-quality medical care and rehabilitation services (3).
Thinking about the ways in which inequities in unintentional injuries may arise can be a
helpful way to identify points at which to intervene (Fig. 5).
A comprehensive approach to reducing inequities in unintentional injuries involves a
combination of policies that address inequities in the root social determinants, as well
as policies that treat the symptoms or attempt to compensate for inequities in the SDH.
This requires a mix of interventions that have short-term actions but a long-term focus,
as well as both simple and complex interventions (Fig. 6).
Socioeconomic context and position
Factors in the global, European or national socioeconomic contexts can influence how
the SDH are distributed. This includes factors in the socioeconomic context which
15
Injuries and inequities
Fig. 5. Levels at which health inequities can arise and be addressed
INTERVENE
ANALYSE
Socioeconomic context and position
(society)
Differential exposure
(social and physical environment)
Differential vulnerability
(population group)
Differential health outcomes
(individual)
Differential consequences
(individual)
Source: Blas & Kurup (35).
Fig. 6. Addressing inequities requires a combination of policies
16
MEASURE
Guidance for addressing inequities in unintentional injuries
influence how risk is produced, distributed and played out in European societies. These
factors can influence which groups are most at risk of injury-related harm, and they may
be modifiable or able to be compensated for (Table 2).
Measures such as legislation, regulation and enforcement – applied to key risk factors
for unintentional injuries – reduce the injury burden generally and can also reduce
inequities, by setting minimum conditions and standards and imposing safe behaviour
and practices. However, a recent survey on road safety found that only 49% of the
countries in the WHO European Region have comprehensive legislation on the five main
risk factors for road traffic injuries: excessive speed, drinking–driving, helmet use, seat
belt use and child car restraints. The survey also showed that the vast majority of the
countries reported that legislation should be enforced more effectively (11).
Safety-for-all strategies, such as legislation that limits access to dangerous products or
substances, have protective impacts, on both unintentional and intentional injuries. One
example is the legislation in England that limits the maximum amount of paracetamol and
aspirin that can be purchased in one transaction, with warnings on the packaging about
the danger of overdose (Box 1). This legislation and its enforcement were effective in
preventing not only accidental poisoning, but also suicides (36).
Box 1. United Kingdom: legislation effective in reducing accidental poisoning
Poisoning caused by paracetamol (a drug which is usually sold without a medical prescription)
is responsible for many accidental deaths, and is a frequent cause of hepatotoxicity and liver
unit admissions. In the United Kingdom, legislation was introduced to restrict pack sizes of
paracetamol sold over the counter. Packs were limited to a maximum of 32 tablets in pharmacies
and to 16 tablets for non-pharmacy sales. A study conducted in England and Wales showed that
the legislation to restrict pack sizes of paracetamol was associated with a significant reduction in
deaths due to paracetamol poisoning over an 11-year period. However, further studies are needed
to investigate how equitably the reduction in deaths is distributed throughout society (36).
Differential exposures
Certain groups may be exposed to factors which increase the risk of unintentional
injury. There is differential exposure to hazards, such as unsafe environments or traffic
conditions. For example, in the United Kingdom, children from more deprived areas
are more likely to walk to school and are less likely to be accompanied by adults than
children from more affluent homes (38).
Effective strategies for reducing exposure to risk may need to target behaviours as well
as infrastructures (Box 2 and Table 3). For instance, child pedestrian journeys to school
can be supervised (behaviour), and safe play areas can be developed (environmental
change). In addition, land use and transport policies, as well as home design regulations,
can have an effect in terms of modifying the exposure to hazards (39).
17
Injuries and inequities
Table 2. Factors in the socioeconomic context that shape inequities and interventions to
consider
Sources/drivers for inequities
Levels and distribution of poverty
Interventions to consider
• Simplify eligibility requirements and support
provided to those without documentation.
• Improve acceptability of services for highrisk groups (staff training, recruitment policies,
gender and cultural sensitivity, opening hours,
location of services).
• Review the continuum of care pathway to
ensure better links between health and social
services for people at risk of poorer outcomes
upon discharge from health care (e.g. homeless
people).
• Provide supported housing to people
discharged from care.
Cultural norms about safety, and gender
norms
E.g. young males have risk-taking
behaviours and lifestyles, encouraged
by masculine norms, expectations and
identity
• Introduce campaigns to promote a culture
of safety which are designed according to
qualitative and quantitative studies on reasons
for unsafe behaviours among vulnerable groups,
and which are designed to specifically reach out
the most disadvantaged.
• Strengthen enforcement on legislation, and
introduce regulations setting safety standards.
• Implement measures on gender norms and
values to address risk-taking behaviours.
• Introduce measures to change harmful
drinking cultures among certain groups (e.g.
men and young people) to prevent drink–driving.
Conditions of home and working
environment, and of recreational areas;
traffic environment; maintenance of
road infrastructure
• Increase safety standards for home and
working environments.
• Conduct regular road safety audits on the
existing road network and incorporate safety in
the design of new roads.
• Produce safety devices (helmets, seat belts,
child restraints) which comply with international
safety regulations.
• Develop safety-oriented legislation that
sets minimum standards and conditions in
the workplace, public and private buildings,
recreational areas and on roads.
18
Guidance for addressing inequities in unintentional injuries
Table 2. contd
Sources/drivers for inequities
Different opportunities for safety:
availability and affordability of safety
equipment
Interventions to consider
• Guarantee affordability of safety equipment
(stair gates, smoke detectors, helmets) by
regulating their price.
• Co-finance the purchase of safety equipment
for less-affluent groups.
• Provide financial incentives, free distribution
and borrowing schemes for child restraints (37).
Social exclusion/marginalization
• Involve people from excluded groups in the
development and implementation of policies that
allow them to fulfil their rights (e.g. to education,
health, housing).
It is important to understand the mechanism that leads to increased exposure to risk
of injury among different social groups. For instance, if parents in disadvantaged social
groups simply have an information deficit, potentially this can be addressed by an
educational approach. However, if children face increased risk because they live in areas
in which they are exposed to high volumes of traffic, then area-wide environmental and
policy measures may be required (39).
Alcohol impairment is a risk factor for unintentional injuries in all socioeconomic
groups, with a stronger association for those groups lower on the socioeconomic
scale. Furthermore, alcohol misuse is one of the strongest predictors for interpersonal
violence and self-inflicted injuries. Interventions aiming to decrease alcohol abuse, such
as reducing access by limiting the opening times of bars and sales points, will lead to
wider societal benefits given the significant role played by alcohol in injury outcomes (3).
Box 2. Lipetskaja oblast in the Russian Federation: safer behaviours through
strengthened enforcement and social marketing campaigns
In 2010 the Russian region of Lipetskaja oblast implemented a multisectoral project on road
safety (Road Safety in 10 Countries). Among the initiatives undertaken were a newly designed
social marketing campaign and a series of public relations initiatives aiming to increase seat belt
use.
Hard-hitting television advertisements were complemented by bill-boards and other media to target
the groups most at risk. During the campaign, enforcement operations by police officers were
increased 10-fold compared to pre-campaign measures. The initiative led to significant improvement
in seat belt use and life saving in the region. However, whether the safety improvements are
equally spread across socioeconomic groups was not evaluated (40, 41).
19
Injuries and inequities
Table 3. How differential exposures could occur and interventions to consider
Sources/drivers for inequities
Differential exposure to unsafe
environments
E.g. people living in deprived
neighbourhoods may be more likely to
be exposed to unsafe environments
Interventions to consider
• Enforce legislation which sets minimum safety
standards in the workplace, home, on roads and
in recreational areas.
• Implement soft engineering approaches, such
as traffic separation and traffic calming measures
for the prevention of road traffic injuries.
• Introduce parenting support programmes
and investment in high-quality early childhood
education and childcare.
• Provide incentives for less-affluent groups in
order to promote use of public transport.
• Introduce population-based measures to
increase lighting in outdoor environments in
deprived areas (tunnels, parks, streets).
Differential exposure to unsafe
practices
• Ensure strict enforcement of legislation on
key risk factors for road traffic injuries (drink–
driving, excess speed, seat belts, child restraints,
motorcycle helmets), accompanied by social
marketing campaigns on those factors.
• Enforce policies which limit alcohol impairment.
• Provide home safety education and visitation
programmes to increase the adoption of safety
practices.
Lack of supervision/enforcement
E.g. children living in deprived
neighbourhoods may experience poor
parental supervision
• Provide home safety education and visitation
programmes to improve parental supervision
and increase the adoption of safety practices.
• Implement community-based interventions to
foster social cohesion.
Differential vulnerabilities
Certain factors make some groups more vulnerable than others to unintentional injuries,
even if their exposure is the same. Vulnerabilities that contribute to inequities can be due
to the presence of disabilities which reduce mobility, as well as unsafe behaviours and
practices, or lack of availability of safety equipment. Interventions targeting people at risk
are a common way of tackling vulnerabilities (see Table 4). Such interventions include
educational programmes providing adequate information on safety practices, and proper
installation and use of equipment, sometimes combined with its free distribution (see
Box 3 and Box 4). A greater vulnerability faced by people from deprived groups does not
exclusively stem from poor knowledge or safety practices. Differences in vulnerability
to injury are also due to barriers that hinder safe practice, for example lack of funds to
spend on child safety equipment and its maintenance.
20
Guidance for addressing inequities in unintentional injuries
Table 4. How differential vulnerabilities could occur and interventions to consider
Sources/drivers for inequities
High cost of safety equipment
Interventions to consider
• Introduce pricing policies for home safety
devices and safety equipment for road traffic
injuries.
• Consider factors such as advocacy, social
marketing, local device production, lowering of
tariffs, and introducing mandatory use, in order
to help stimulate market growth.
• Carry out free distribution of safety
equipment among less-affluent groups.
• Implement borrowing schemes for child
restraints and other safety equipment.
Low level of education
E.g. people with lower levels of
education might not be able to read
safety instructions properly, or may
have less opportunity to acquire safety
skills
• Increase the readability of safety instructions,
especially among groups with low levels of
education.
• Offer appropriate training and opportunities
(affordable to all) for the acquisition of skills
such as swimming and driving.
• Improve literacy levels.
Less resilience/support to cope with
stressors
• Build social support networks in disadvantaged
areas, with peers leading by example.
Higher rates of co-morbidities in certain
groups
• Take a comprehensive approach to improving
living conditions, as well as the financial and
social well-being of disadvantaged groups.
E.g. disadvantaged groups are more
likely to have multiple noncommunicable
disease risk factors, and poorer
general health, making it more difficult
to protect themselves from injurious
events
• Scale up population-based prevention
measures (alcohol control, physical activity) for
other preventable noncommunicable diseases.
• Scale up access to universal primary health
care, ensuring disadvantaged groups are
supported to access preventive care.
Box 3. France: home counselling and free safety devices increase safe behaviours
among the poor
Less-affluent families are more vulnerable to injuries and have fewer financial resources for
prevention. A study conducted in France assessed the effectiveness of the distribution of free
preventive devices, such as smoke detectors, phone stickers with the number of the poison control
centre, electric outlet covers, protective table corners, and non-skid bathtub mats, combined with
home counselling. Not only did the intervention enable families to change their behaviour and
to implement safety measures in their homes, it also triggered a multiplying effect of additional
safety improvements not related to the provided devices. In other words, the safety intervention
increased safety consciousness (42).
21
Injuries and inequities
Box 4. Incentives combined with education increase the use of booster seats
Booster seats are designed to be used by children aged 4 to 8 years, while travelling in motor
vehicles. They aim to raise the child off the vehicle seat so that the adult seat belt fits correctly and
the child can travel in greater comfort and safety. A Cochrane review showed that the distribution
of free booster seats, combined with education on their use, had a marked beneficial effect, as
did incentives (for example, booster seat discount coupons or gift certificates). While the use of
booster seats increased, no investigation was made into the variation of the impact on safety in
different social groups (37).
Differential health outcomes
In addition to differential exposures and vulnerabilities that put groups at greater risk of
unintentional injuries, various health system factors can also cause certain groups to
experience poorer health outcomes related to injuries.
Studies have shown that many deaths from injuries occur in a pre-hospital setting,
especially among low-income areas and populations. Effective policies and actions to
reduce differential health outcomes include improving response and delivery times in
emergency trauma care, as well as strengthening the availability of and access to posttrauma care (43).
Differences have also been observed in Europe in the treatment received within the
health system, based on socioeconomic factors, and this can also contribute to inequities
in health outcomes.
Levelling up the health outcomes of the most disadvantaged would be beneficial to
societies at large, because loss of productivity would be avoided. Table 5 shows ways
in which differential health outcomes occur and interventions that should be considered
to tackle the inequities that arise.
Differential consequences
Consequences of injuries are long-lasting and widespread, including, for instance,
post-traumatic stress disorders. Not only is the risk of incurring an injurious event
higher among the poorest, but the severity and long-term consequences of such
events are unequally distributed in societies. Disadvantaged people not only have a
higher probability of incurring injuries and having unfavourable health outcomes; they
also suffer more severe consequences due to lack of social protection measures, or
reduced or no access to rehabilitation services. Socioeconomic consequences can
include, for instance, permanent disability, and exacerbation of household poverty. For
severely injured children in the poorest families, consequences can include missing out
on education, and can lead to marginalization and lack of peer support. Table 6 details
the drivers for inequities and the interventions to be considered in order to combat them.
22
Guidance for addressing inequities in unintentional injuries
Table 5. How differential health outcomes could occur and interventions to consider
Sources/drivers for inequities
Cost of accessing care
Interventions to consider
• Provide universal health services.
• Remove financial barriers for those who
cannot pay (user charges, transport costs,
childcare provided to parents).
Non-financial barriers to accessing care
• Review the continuum of care pathway to
ensure better linkages between health and social
services for people at risk of poorer outcomes
upon discharge.
• Simplify eligibility requirements and support
to those without documentation.
Different treatment within the health
care system
E.g. insurance status is an important
predictor of hospital admission and use
of specialized post-hospital care
• Provide training for primary health care
professionals and increase awareness of
the distribution of unintentional injuries by
socioeconomic factors.
• Identify high-risk groups and individuals with
repeated injury events.
• Monitor equity in service provision, along with
effectiveness.
• Follow up after injurious events, especially
among deprived groups.
Groups with higher co-morbidities
• Improve access to primary health care for
underserved or high-need groups.
• Address causes of social exclusion,
disempowerment, low levels of education,
low income and poor living conditions, all of
which contribute to poorer general health in
disadvantaged groups.
Box 5. Vision Zero in Sweden: an example of a successful multisectoral approach
“It can never be ethically acceptable that people are killed or seriously injured when moving within
the road system”. It was with this slogan that the Swedish Parliament adopted the Vision Zero
approach, which represented a paradigmatic shift in addressing the issue of road safety. According
to Vision Zero, crashes within the transport sector will always occur, due to human error; however,
no crash should exceed the human tolerance to physical impact. The blame for fatalities in the
road system is attributed to the failure of the road system rather than to the road user. Vision Zero
requires a systematic approach based on four elements: ethics, responsibility, a philosophy of
safety, and the creation of mechanisms for change. Vision Zero is now applied in many countries
and is regarded as a safety tool for all, feasible in any type of road transport system and at any
stage of development (44).
23
Injuries and inequities
Table 6. How differential consequences could occur and interventions to consider
Sources/drivers for inequities
Interventions to consider
Impoverishment for lower income
families resulting from loss of income
• Implement adequate social protection
policies, including universal provision of highquality early childhood education, free universal
education and health care.
Cultural norms, stigma
• Implement programmes to reintegrate victims
of unintentional injuries into the labour market
and society.
• Implement concerted multisectoral policies,
such as Zero Vision (Box 5) in order to reduce
severe consequences.
• Make fire alarms and fire safety equipment
mandatory in low-income housing.
Out-of-pocket payments
E.g. health care costs can cause
households to incur catastrophic
expenditures, which can in turn push
them into poverty
Young deprived adults are more likely
to be injured or killed when consuming
alcohol than older adults, probably due
to differences in risk-taking behaviour
• Ensure health financing policies reduce
catastrophic health expenditures.
• Provide financial aid for those people not
covered by health insurance.
• Raise the price of alcohol to induce a
disproportionate effect on younger drinkers.
Key policy recommendations
• A comprehensive approach to reducing inequities in unintentional injuries requires action that
includes a mix of long- and short-term impacts and knowledge of the social determinants of
inequities, acting on both individuals and environments.
• Unintentional injuries are not accidents, but rather predictable and preventable events.
Effective policies exist to decrease the burden of injuries and these are also cost-effective.
• Safety-for-all policies, such as legislation, regulation or community-based programmes aim
to reduce exposure to hazards which are found in the home, workplace and in means of
transport.
• Groups most at risk of injuries need targeted interventions. These should be based on the
distinct pathways and mechanisms which lead to injury, and which can be different in each
social group or area.
• Every policy and intervention tackling unintentional injuries should incorporate the equity
dimension. Whether the intervention produced the intended effect in each social group
should also be evaluated.
24
Guidance for addressing inequities in unintentional injuries
Key policy recommendations contd
• Differential access to and treatment within the health system contribute to inequities in
injuries. Actions to increase accessibility and affordability of care and rehabilitation can
mitigate differential health outcomes.
• Everyone should be given an equal opportunity to protect their health. Safety equipment,
such as child restraints, smoke alarms and stair gates should be accessible to all, regardless
of ability to pay.
• Comprehensive rehabilitation and support programmes should be implemented, particularly
favouring the most disadvantaged. Such programmes should include multisectoral action on
health, social and labour aspects (including gender).
Checklist: are you on track?
1. Do you routinely measure the burden of unintentional injuries by socioeconomic group
(e.g. gender, ethnicity, education level)?
2. Have you implemented safety-for-all strategies, such as legislation and enforcement on
key risk factors for road traffic injuries or safety requirements for home appliances?
3. Have you identified which groups were most at risk of each category of injury, and are
they clearly prioritized in your strategies and plans?
4. Do you routinely assess the equity impact of injury policies and plans before they are
implemented?
5. Can the most marginalized groups in society meaningfully participate in decision-making
processes about injury prevention policies?
6. Do you have robust policies in place with the following specific goals?
• To set safety standards for buildings, public places, recreational areas, and so on.
• To regularly conduct safety audits on existing and new roads.
• To increase availability and affordability of safety equipment.
• To improve access to health care among less-affluent societal groups.
• To reduce harmful consequences from injuries in vulnerable groups.
• To protect vulnerable road users, such as pedestrians, cyclists and motorcyclists.
7. Do you have effective policies in place to address the root social determinants of
unintentional injuries? Such measures should include:
• social protection, especially for families with children and the unemployed;
• high-quality early childhood education and parenting support;
• policies to reduce social exclusion;
• improving psychosocial working conditions for low-income workers.
25
Injuries and inequities
Checklist: are you on track? contd
8. Do you evaluate the impact of all unintentional injury interventions on different social
groups?
9. Have you set targets for reducing unintentional injuries in different social groups?
10. Is there clear accountability and leadership for reducing inequities in unintentional
injuries?
26
Where to find out more
Unintentional injuries in Europe
• European facts and “Global status report on road safety 2013” (11).
• European status report on road safety. Towards safer roads and healthier transport
choices (45).
• World report on road traffic injury prevention (46).
• European report on child injury prevention (12).
• Preventing injuries in Europe: from international collaboration to local
implementation (47).
Policy options to address unintentional injuries
• Global Plan for the Decade of Action for Road Safety 2011–2020 (6).
• Youth and road safety in Europe. Policy briefing (48).
• Addressing the socioeconomic safety divide: a policy briefing (3).
• Child and adolescent injury prevention: a WHO plan of action 2006–2015 (49).
• A WHO plan for burn prevention and care (50).
• Developing policies to prevent injuries and violence: guidelines for policy-makers
and planners (51).
• Preventing injuries and violence. A guide for ministries of health (52).
• European inventory of national policies for the prevention of violence and injuries.
WHO Regional Office for Europe online database to facilitate national monitoring
and reporting (53).
• Evidence for gender responsive actions to prevent and manage injuries and
substance abuse. Young people’s health as a whole-of-society response (54).
Actions to reduce health inequities through action on SDH
• Equity, social determinants of health and public health programmes (35).
• Review of social determinants and the health divide in the WHO European Region:
final report (55).
• Strategic review of health inequalities in England post-2010 (Marmot Review).
Task group 8: priority public health conditions. Final report (56).
27
Injuries and inequities
• Resource of health system actions on socially determined health inequalities.
WHO Regional Office for Europe online database (57).
• Action:SDH. A global electronic discussion platform and clearing house of actions
to improve health equity through addressing the SDH (58).
• European Portal for Action on Health Inequalities. An Equity Action partnership
information resource on health equity and SDH in Europe, including a database of
policy initiatives (59).
Policy equity assessment tools
• Health inequalities impact assessment. An approach to fair and effective policy
making. Guidance, tools and templates (60).
• Methodological guide to integrate equity into health strategies, programmes and
activities (61).
• Tools and approaches for assessing and supporting public health action on the
social determinants of health and health equity (62).
Data disaggregation and tools
• Equity in Health project interactive atlases. WHO Regional Office for Europe online
resource (63).
28
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